物诊体格检查15心脏物理诊断

心脏的物理诊断Examination

of

the

cardiovascular

system首都医科大学第一临床医学院谢錦萍心脏物诊的意义

There

is

wrong

tendency

that

some

doctors

areignoring

physical

examination.心脏物诊的意义

Some

cardiovascular

diseases

can

be

diagnosedsimply

with

history

taking

and

proper

physicaldiagnosis

ofachieved

byexamination

,

such

as,

a

clearrheumatic

valve

disease

can

beauscultation.Most

signs

of

cardiovascular

system

can

betraced

by

physical

examination,such

as

theintensity

of

heart

sounds,Gallop

rhythm,

heartmurmur,

Click、pericardial

friction

rub

andtransitory

arrhythmia.

Physical

examination

is

safe

,

simple

and

easyto

perform

.Based

onmedicationthe

situation

inand

insuranceChina,

lack

ofpolicy,

doctorsshould

be

experienced

on

their

examinationtechnique.心脏物诊基本注意事项1

、

Ensure

adequate

lighting

and

quite

pacificenvironment2、Ensure

suitable

positionThe

examiner

is

generally

on

the

patient

rightTwo of

routine

positions:

Supine、sitting

positionSpecial

physical

sign、special

positionsuch

as:

murmur

of

MS(mitral stenosis)

by

auscultation.3、Patient

should

be

stripped

to

the

waist(

It

is

difficult

auscultatingthrough

clothing)4、A

pair

of

stethoscope

with

high

quality

is

necessary

in

auscultationpercussion5、Examination

should

be

performed

in

proper

orders.the

order

of

examination

is

as

follows:

Inspection

palpationauscultation视诊和触诊Attention1、Time

phase：systole

or

diastole

Pericardial

movements

should

be

timed

by

using

thesimultaneously

palpated

carotid

pulse

（

angle

ofmandible

），the

rise

of

impulse

stands

for

systole

(S1)and

the

leave

of

impulse

stands

for

diastole(S2).2.Pericardial area

:The

whole

pericardial

area

is

projection

ofheart

and

major

vessels

on

chest.心前区就是指心脏在体表的投影具体位置是:1.左侧第2肋软骨下缘，距胸骨左缘1.2厘米处。2.右侧第3肋软骨上缘，距胸骨右缘1厘米处。3.右侧第6胸肋关节处.4.左侧第5肋间隙，距前正中线约7-9厘米处。

用弧线连结上述四点，即为心在胸前壁的体表投影Pericardial

area

is

considered

to

be

divided

into

several

areas

to

facilitated

examination.Aortic

valve：

2nd

right intercostal

space,

medial

to

sternum.Pulmonary

valve：

2nd

or

3rd

left

intercostal

space,

medial

to

sternum.Right

ventricle

:the

left

sternal

border

4th

、5th

or

3rd

,4th,5th

intercostal

space,

medialto

sternum.Apex

:

medial

and

superior

to

the

intersection

of

the

leftmidclavicular

line

(

LMCL)and

the

4th

、5th

intercostal

space.Subxiphoid

area

：upper

abdomen

and

subxiphoidHeart’s

post-anterior

view

andsurfaceprojection视诊InspectionATTN：vertical

look

at

best

be plished

with

the

examine

standing

at

the

side

or

foot

of

a

supine

patient

of

the

bed

or

examiningtable.

See

if bilateral

sides

of

chest

are

at

the

same

level

.tangent

look

at

See

if

any

lateral

part

of

chest

is

at

the

same

level

orany prominent

part.normal：bilateral

side

of

chest

is

on

the

same

level

,

haven’tpromontory

and

hollowAbnormalities：

Precordial

prominence

is

most

striking

if

cardiacenlargement

developed

before

puberty,

but

may

also

bepresent

in

patients

in

whom

cardiomegaly

developed

inadult

life,

after

the

period

of

thoracic

growth.Inspection----心前区隆起及凹陷Precordial prominence

:Congenital heart

diseaseEarly

presented

RHD

(rheumatic

heart disease)、Prominent

pericardial

effusionPrecordial

concavity:pigeon

chest

and

funnel

chest

,

which

may

be

associatedwith

congenital heart

disease.Inspection----心尖搏动Significance

of

apical

pulsation：Help

to

ensure

the

time

phase

of

systoleHelp

to

signify

S1

and

S2

especially

for

auscultation

thatdistinguish

systole

and

diastole.Help

to

signify

the

cardiac

enlargement

or

replacement.Therefore,note

the

location、intensity、range、rhythmand

frequency

of

pulsation.Normal

apical

pulsation：

An

apical

pulsation,

normally

visible,

is

located

on5th

left

intercostal, 0.5～1.0cm

inside

lateral

to

MCL(midclavicular

line

) and

not

exceeding

2.5cm

indiameter.

An

apical

pulsation

is

invisible

in obesity、femalebreast

drop.1、心尖搏动移位（1）pulsation

changeunder

physiologicalconditionsage

：children’s apex

pulsation

slightly

moved

upwardpositionsupine：apex

pulsation

slightly

moved

upward(diaphragm

lift)left

lateral：apex

pulsation

is

left

displaced

2～3cmright

lateral：apex

pulsation

is

right

displaced

1～2.5cmshapeshort

fat

normal

weight

or

overweight:

lateralize

and

upward

into

the

4th

interspaces.slim：

downward

displacement

into

the

6th

interspaces.respirationapex

pulsation

is

displaced

upward(呼气）

or

downward（吸气）

parallel

withdiaphragm

while

respiration.（2）pathology：such

as

diseases

of heart、chestand

abdomenHeart

diseases：cardiomegaly

left

ventricle

enlargement:

pulsation

displaced

left

anddownwardright

ventricle

enlargement:

pulsation

displaced

left

andupwardbilateral

enlargement:

pulsation

displaced

left

anddownward, cardiac

border

enlarged

bilateral.Chestdiseases：胸腔积液或气胸A

lateral

pleural

effusion

（胸腔积液）andpneumothorax

（气胸）→mediastinum

（纵膈）

tohealth

side

→apex

pulsation

displaced

to

health

side.胸膜增厚或肺不张A

lateral

lung

collapse

or

adhesives

→mediastinum（纵膈）moved

to

diseased

side→apex

pulsation

displacedto

diseased

side.胸廓和脊柱畸形Chest

and

spine

deformity

→change

in

heartposition→related

apex

pulsation

displacementAbdominal

diseases：massive

ascites

/abdominal

mass→pressure↑→diaphragm

location↑→horizontalheart→apex

pulsation

displaced

upward2、心尖搏动强度和范围的改变Intensity

variation

is

mainly

caused

by

physiologicalconditions.physiological

conditionsthick

chest

wall

and

narrow

intercostals

space：decreasedapex

pulsation

and

narrowed

rangethin

chest

wall（in

children）and

wide

intercostals

space： increased

apex

pulsation

and

enlarged

rangeextreme

activity

and

emotion：prominent

pulsation

and

increased

heart

beat（2）pathological

conditions：increased

pulsation：left

ventricle

hypertrophy、hyperthyroidism

、fever、anemiadecreased

pulsation：myocardial

disease：acute

myocardial

infarction、cardiomyopathypericardial

effusionleft

pleural

effusion、pneumothorax、emphysema3、负性心尖搏动inward

pulsation：retract

pulsation

can

be

elicited

when

extensive

stickiness(粘连)with

surrounded

tissue

in

adherent

pericarditisRV

enlarged

significantly：clockwise

rotation，LVdisplaced

backwardInspection----心前区搏动1、心底部搏动2nd

left

intercostal

space

：healthy

young

adults→slight

pulsation.pulmonary dilation、pulmonary

hypertension2nd

right

intercostal

space,

medial

to

sternum：ascending

aortic

aneurysm、aortic

aneurysm.2、胸骨左缘3rd

and

4th

搏动：significant

RV

enlargement：front

wall

of

hypertrophiedRV

moved

right

and

forward

during

systole.3、剑突下搏动RV

enlargement：increased

pulsation

with

deep

inspiration

（digital

press

up

andbackward

on

subxiphoid，

feel

pulsation

on

finger

tips）abdominal

aortic

aneurysm：

decreased

pulsation

with

deep

inspiration(pulsation

impactpalm

side).Deep

breath

increase

distance

of

aorta

and

abdominal

wall

caused

decreased

pulsation触诊PalpationPoints：There

is

close

relation

in

palpation

and

inspectionwith

right

hand, hypothenar（小鱼际）→thrill

closure

with

middle

finger

and ring

finger

→apicalimpulsePalpation--apical

and

pericardial

impulseSignificanceTo

elicit

position,

intensity

and

range

of

apical

impulse,

with

palpation

is

moreaccurate

than

inspection，can

further

assure

and

confirm

the

inspection

resultssome

invisible

signs

can

be

find

outcan

help

timing

thrill、heart

sound

and

murmur.apical

impulseincreased

apical

impulse：left

ventricle

enlargement、hyperthyroidism、fever、anemia.apical

heave

or

lift：wide

range、prominent

outward

heartbeatsustained

outward

movement

of

an

areamore

than

2

to

3

cm

in

diameter;a

reliable

symbol

of

left

ventricle

hypertrophy(2)

decreased

pulsation：pericardialeffusion,

cardiomyopathy,

pluraleffusion,

emphysema.precordial

impulseprecordial

heave

or

lift：（right

ventricle

area、L4）RV

hypertrophy：Hypertrophic

right

ventricular

wallrotate

forward impulse

in

upper

abdomen

：RV

enlargement、abdominal

aortic

aneurysm（3）aortic

valve：ascending

aortic

aneurysm（4）pulmonary

valve：pulmonary

dilation、pulmonary

hypertensionPalpation--ThrillThrill

is

a

palpable

slight

vibration

and

is

not

visible.

Thrill

is

a

cat

asthma.

when

examination,

put

flat

orhypothenar of

hand

touch

different

precordial

area.Thrill

is

one

of

characteristic

sign

of

cardiac

disease,

justlike

cardiomegaly.Mechanism

of

Thrill：turbulence

,

(

caused

by

blood

flow

pass

stenosis

valves,or

abnormal

pathway

into

a

wide

area)

which

initiatevibration from

cardiac

valves,

ventricle

and

vessels

wallto

chest

wall.Such

as VSD

(Ventricular Septal

Defect)

and

PDA(Patent

Ductus

Arteriosus)normally，

the

intensity

of

Thrill

depends

onstenosis

area,

blood

flow

speed

and

pressure

drop（grads). More

severe

the stenosis

,

much

louderthe

thrill

is.However,

the

audible

murmur

does

not

mean

thrillis

palpable.(

because

there

is

different

sensitivity

tofeel

vibration

in

different

part

of

human

body.Finger

touching

is

sensitive

to

low

frequencyvibration

)

thrill

according

timing

and

position.It

is

divided

intosystolic,

diastolic

and

continuesSystolic

thrill：ASPSVSD、IHSSMSaortic

valve（R2）pulmonary

valve

(L2)L3-4

intercostals

Diastolic

thrill：apex

Continues

thrill：pulmonary

valve(L2)PDAPalpation--pericardial

rubsA

feeling

of friction

and

vibration

in

pericardium

which

issimilar

to

pleural

rub.The

human

pericardium

normally

contains

up

to

50

ml

ofclear

fluid

between

visceral

and

parietal

layers

to

maintainsmooth

movement

of

heart.

Deposition

of

fibrin

consistof

rough

surface

between

two

layers

caused

frictionradiated

to

chest

wall

which

is

palpable

during

the

processof

precarditis.The

pericardial

friction

rub

isclassicallydescribedashaving

threecomponents

:thatare

related

to

cardiac

motion

during

atrialsystole

(presystole),

ventricularsystole,

andrapid

ventricular

filling

in

early

diastole.Palpation

site：bestpalpable

in

L4（not

covered

by

lungtissue）during

both

systole

and

diastole，patient

sitting

upand

leaning

forward

and

atthe

end

of

expiration.Pericardial

rubs

decreased

with

increasedpericardial

effusion.PercussionInspection,

palpation and

auscultation

are far

morehelpful

than

percussion

in

cardiac

examination，whilepercussion

is

necessary

when

the

other

three

failed

toelicit.aim：

to

determine

cardiac

and

major

vessels’

size,configuration

and their

situation

in

thoraxposition：

supine

or

sitting

upward,

breathing

freelywith

the

examiner

is

positioned

on

the

right

side

tothe

patientorientationplacing

the

middle

finger

of left

hand

on

the

chest

walland

tapping

it with

the

opposite

middle

finger

alongintercostalssitting：

the

middle

finger

is

parallel

to

heart

border（perpendicular

to

intercostals）supine：

the

middle

finger

is

parallel

to

intercostals（perpendicular

to

heart

border

）sequence：start

with left

heart

border，then

the

right

heartborder

from

outside

to

inside,

downward

to

upwardintensity：just

heavy

enough

to

detect

resonance

according

topatient’s body

size、fat、thin.Tapping

equally.dullnessHeart

is

a

part

solid

organ

of

which

resonance

isdetected

“absolute

dullness”，while

the

bilateralpart

of

heart

is

detected

relative

dullness

inpercussion.

The

transition

of

resonance

intoabsolute

dullness

means

the

uncovered

part

ofheart

is

detected.Percussion—cardiac

dullnessRight

heart

borderLeft

heart

borderfrom

its（肝上界）upper

intercostal,from

outside

to

inside,downward

to

upwardStartwith

2～3cmoutside

of massive

apicalimpulse, from

outsideto

inside, downward

toupwardUp

to

2nd

intercostalUp

to

2nd

intercostalNote

and

measurement

(with

rigidity

ruler)Perpendicular

distance

from

anteriormidline(AM)

to

every

notesPerpendicular

distancefrom

leftMidclavicular

Line

to

anterior

midlineNormal

heart

border

in

percussion：normal

left

heart

border

does

not

exceed

left

border

ofsternum

in

2nd

intercostal

space;

there

is

an

expendingcurve

formed

from

3rd、4th

and

5th

intercostal

space.Right

border

is

roughly

along

the

right

border

of

sternumexcept

in

4th

intercostal.MCL＝8~10cmThe

component

of

heart

borderAa2～3

cmⅡ2～3

cmpulmonaryright

atria2～3

cmⅢ3.5-4.5

cmleft

auricle3～4

cm

Ⅳ5～6

cmleft

ventricleⅤ7～9

cmleft

ventriclewaist：

between

aortic

node

and

edge

of

left

ventricle.Percussion--dullness

variation

and

related

pathologydullness

variation

and

clinic

significance1、cardiac

diseaseleft

ventricle

enlargement：心腰部加深，left

borderdisplaced

left

and

downward靴形心：shoe

shape

（主动脉心型）aortic

valveinsufficiency、hypertensionright

ventricle

enlargement：slight

enlargement：increased

area

of

absolute

dullnessborder

during

the

early

stage。severe

cardiomegaly：the

area

of

relative

dulness

borderincreased

bilaterally.Such

as：mitral

stenosis.Bilateral

ventricular

enlargement：bilateral

enlargment

in

dullness

site

and

the

leftborder

displaced